Healthcare Provider Details

I. General information

NPI: 1922478114
Provider Name (Legal Business Name): SOCORRO MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10720 N LOOP DR SUITE A
SOCORRO TX
79927-4409
US

IV. Provider business mailing address

PO BOX 221287
EL PASO TX
79913-4287
US

V. Phone/Fax

Practice location:
  • Phone: 915-351-4010
  • Fax: 915-309-1816
Mailing address:
  • Phone: 915-351-4010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberN3416
License Number StateTX

VIII. Authorized Official

Name: ADEKUNLE ADEDAYO ADEDEJI
Title or Position: PRESIDENT
Credential: MD
Phone: 915-351-4010